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N. Bacalso Avenue Corner Ramon Rallos Sr. Streets, Cebu City 2008

This document appears to be a record of clinical experience from a College of Nursing in Cebu City, Philippines. It includes a record of two surgical cases performed by the applicant. It documents the patient name and diagnosis, procedure performed, anesthesia used, surgeon and hospital. It is signed by the applicant and verified by supervising faculty to confirm the applicant's participation. It provides certification of the applicant's clinical experience to the Board of Nursing.

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Daryl Diez
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140 views4 pages

N. Bacalso Avenue Corner Ramon Rallos Sr. Streets, Cebu City 2008

This document appears to be a record of clinical experience from a College of Nursing in Cebu City, Philippines. It includes a record of two surgical cases performed by the applicant. It documents the patient name and diagnosis, procedure performed, anesthesia used, surgeon and hospital. It is signed by the applicant and verified by supervising faculty to confirm the applicant's participation. It provides certification of the applicant's clinical experience to the Board of Nursing.

Uploaded by

Daryl Diez
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Republic of the Philippines

Professional Regulation Commission


Board of Nursing
Cebu City

College of Nursing
College of Technological Sciences-Cebu
N. Bacalso Avenue corner Ramon Rallos Sr. Streets
Cebu City

Name of Student :
Name and Address of School : COLLEGE OF TECHNOLOGICAL SCIENCES-CEBU
N. Bacalso Avenue corner Ramon Rallos Sr. Streets, Cebu City
Accreditation Level (if any) : none Year Granted :
Date School/Program was recognized : April 01, 2008 Commission on Higher Education Region VII Government Recognition Number : 022 Series: 2008
First Course (if any) : none School Graduated from : Not applicable Year:Not applicable
Year of Admission in the Bachelor of Science in Nursing Program :
Year Graduated (BSN Program) :

I. MAJOR OPERATIONS
Signature of
Date of Name of Types of Name of Name of O.R. Scrub
No. Case No. Diagnosis Operation Performed Name of Surgeon O.R. Scrub
Operation Patient Anesthesia Hospital Nurse
Nurse

Himulatan,
Cholecystectomy with Intra Operative General Dr. Melvin Cebu City Recopelacion, Relyn
March 05, 2010 352889 Salvador Cholelithiasis with Cholecystitis
Cholangiogram Anesthesia (Dapitilla) Ocleasa, Medical Center C., R.N.
(Gaquing)

Gorit, Juanito
Jr. (Briones) Fracture, Closed, Complete Middle Open Reduction Internal Fixation Right General Dr., Cris Cecil Cebu City Barriga, Loreto P.,
2 March 12, 2010 353351
third Right Clavicle Clavicle Anesthesia (Chan) Abbu Medical Center R.N.

PREPARED BY:
Daryl C. Diez
Class 2010

Supervised by: Noted by: Concurred by: Approved by:

NERENITA Y. LIM CARMELITA T. VILLANOBOS LYRMA S. SOLEDAD ERLINDA G. OLIVA


Signature over printed name of Faculty Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed name of Dean
Date Signed : Date Signed : Date Signed : Date Signed :
Degree : R.N., M.N. Degree : R.N., M.A.N., D.M. Degree : R.N., M.H.A., M.N. Degree : R.N., M.N.
a) PRC No. : 0072331 a) PRC No. : a) PRC No. : 0079370 a) PRC No. : 0016598

Valid until : March 07, 2011 Valid until : Valid until : October 5, 2011 Valid until :

b) PNA No. : 1838 b) PNA No. : b) PNA No. : 3373 b) PNA No. : 1837
Valid Until : LIFE MEMBER Valid Until : LIFE MEMBER Valid Until : LIFE MEMBER Valid Until : LIFE MEMBER
c) ANSAP No. : 009 c) ADCPN No. : 12708
Valid Until : LIFE MEMBER Valid Until :
I declare under oath that these cases had been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is a true, correct and complete pursuant to
the provisions of pertinent laws, rules and regulations of the Republic of the Philippines.
__________________________
Signature of Applicant
Subscribed and sworn to before me this __________ day of _______________________ 2010, Cebu City, Philippines.
Republic of the Philippines
Professional Regulation Commission
Board of Nursing
Cebu City

College of Nursing
College of Technological Sciences-Cebu
N. Bacalso Avenue corner Ramon Rallos Sr. Streets
Cebu City

Name of Student :
Name and Address of School : COLLEGE OF TECHNOLOGICAL SCIENCES-CEBU
N. Bacalso Avenue corner Ramon Rallos Sr. Streets, Cebu City
Accreditation Level (if any) : none Year Granted :
Date School/Program was recognized : April 01, 2008 Commission on Higher Education Region VII Government Recognition Number : 022 Series: 2008
First Course (if any) : none School Graduated from : Not applicable Year:Not applicable
Year of Admission in the Bachelor of Science in Nursing Program :
Year Graduated (BSN Program) :

I. MAJOR OPERATIONS
Signature of
Date of Type of Name of Name of O.R.
No. Case No. Name of Patient Diagnosis Operation Performed Name of Surgeon O.R. Scrub
Operation Anesthesia Hospital Scrub Nurse
Nurse

Gravida 4 Para 4 Pregnancy Uterine 40 weeks Age of Gestation


Diamante, Lerna delivered still birth female General Cebu City Amacna, Julnor
3 March 25, 2010 200690 Primary Low Transverse Dr., Kira F. Yao
(Dongalio) Body Weight= 2950 grams Ballard Score=0 Intrauterine Fetal Anesthesia Medical Center M., R.N.
Cesarean Section
Distress Placenta Previa Fetalis

Lubiano, Luwis
General Cebu City Balancas, Romil
4 March 26, 2010 250890 Alfred Hydrocephalus Post Meningitic Ventriculo Peritoneal Right Dr., Jaime P. Perez
Anesthesia Medical Center Galahad M., R.N.
(A)

PREPARED BY:

Daryl C. Diez
Class 2010
Supervised by: Noted by: Concurred by: Approved by:

NERENITA Y. LIM CARMELITA T. VILLANOBOS LYRMA S. SOLEDAD ERLINDA G. OLIVA


Signature over printed name of Faculty Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed name of Dean
Date Signed : Date Signed : Date Signed : Date Signed :
Degree : R.N., M.N. Degree : R.N., M.A.N., D.M. Degree : R.N., M.H.A., M.N. Degree : R.N., M.N.
a) PRC No. : 0072331 a) PRC No. : a) PRC No. : 0079370 a) PRC No. : 0016598

Valid until : March 07, 2011 Valid until : Valid until : October 5, 2011 Valid until :

b) PNA No. : 1838 b) PNA No. : b) PNA No. : 3373 b) PNA No. : 1837
Valid Until : LIFE MEMBER Valid Until : LIFE MEMBER Valid Until : LIFE MEMBER Valid Until : LIFE MEMBER
c) ANSAP No. : 009 c) ADCPN No. : 12708
Valid Until : LIFE MEMBER Valid Until :
I declare under oath that these cases had been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is a true, correct and complete pursuant to
the provisions of pertinent laws, rules and regulations of the Republic of the Philippines.
__________________________
Signature of Applicant
Subscribed and sworn to before me this __________ day of _______________________ 2010, Cebu City, Philippines.
Republic of the Philippines
Professional Regulation Commission
Board of Nursing
Cebu City

College of Nursing
College of Technological Sciences-Cebu
N. Bacalso Avenue corner Ramon Rallos Sr. Streets
Cebu City

Name of Student :
Name and Address of School : COLLEGE OF TECHNOLOGICAL SCIENCES-CEBU
N. Bacalso Avenue corner Ramon Rallos Sr. Streets, Cebu City
Accreditation Level (if any) : none Year Granted :
Date School/Program was recognized : April 01, 2008 Commission on Higher Education Region VII Government Recognition Number : 022 Series: 2008
First Course (if any) : none School Graduated from : Not applicable Year:Not applicable
Year of Admission in the Bachelor of Science in Nursing Program :
Year Graduated (BSN Program) :

I. MAJOR OPERATIONS
Signature of
Date of Type of Name of Name of O.R.
No. Case No. Name of Patient Diagnosis Operation Performed Name of Surgeon O.R. Scrub
Operation Anesthesia Hospital Scrub Nurse
Nurse

Gravida 2 Para 2002 Pregnancy Uterine 39 weeks Age of


Gestation delivered live male, Birth Weight= 1000 grams APGAR
Tugot, Shine Repeat Low Transverse Spinal Cebu City Mendoza, Judee-
5 April 17, 2010 201120 Score 9,10 Previous Cesarean Section 1x Secondary +0 Dr., Kira F. Yao
(Gahi) Cesarean Section Anesthesia Medical Center lyn Y., R.N.
Cephalopelvic disproportion (2008 Vicente Sotto Memorial
Medical Center)

PREPARED BY:

Daryl C. Diez
Class 2010

Supervised by: Noted by: Concurred by: Approved by:

NERENITA Y. LIM CARMELITA T. VILLANOBOS LYRMA S. SOLEDAD ERLINDA G. OLIVA


Signature over printed name of Faculty Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed name of Dean
Date Signed : Date Signed : Date Signed : Date Signed :
Degree : R.N., M.N. Degree : R.N., M.A.N., D.M. Degree : R.N., M.H.A., M.N. Degree : R.N., M.N.
a) PRC No. : 0072331 a) PRC No. : a) PRC No. : 0079370 a) PRC No. : 0016598
Valid until : March 07, 2011 Valid until : Valid until : October 5, 2011 Valid until :

b) PNA No. : 1838 b) PNA No. : b) PNA No. : 3373 b) PNA No. : 1837
Valid Until : LIFE MEMBER Valid Until : LIFE MEMBER Valid Until : LIFE MEMBER Valid Until : LIFE MEMBER
c) ANSAP No. : 009 c) ADCPN No. : 12708
Valid Until : LIFE MEMBER Valid Until :

I declare under oath that these cases had been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is a true, correct and complete pursuant to
the provisions of pertinent laws, rules and regulations of the Republic of the Philippines.
__________________________
Signature of Applicant
Subscribed and sworn to before me this __________ day of _______________________ 2010, Cebu City, Philippines

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